| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
9,019 |
3,183 |
$894K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,539 |
2,029 |
$351K |
| D1351 |
Sealant - per tooth |
10,160 |
2,837 |
$266K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,329 |
546 |
$189K |
| D1120 |
Prophylaxis - child |
4,885 |
4,813 |
$171K |
| D0210 |
Intraoral - complete series of radiographic images |
2,622 |
2,579 |
$153K |
| D0120 |
Periodic oral evaluation - established patient |
4,461 |
4,393 |
$124K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,356 |
561 |
$111K |
| D1110 |
Prophylaxis - adult |
2,046 |
2,023 |
$107K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,989 |
6,882 |
$99K |
| D0272 |
Bitewings - two radiographic images |
3,642 |
3,597 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,841 |
2,797 |
$79K |
| D0145 |
Oral evaluation for a patient under three years of age |
444 |
426 |
$60K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
413 |
280 |
$39K |
| D0274 |
Bitewings - four radiographic images |
742 |
728 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,327 |
1,150 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,191 |
1,173 |
$14K |
| D2140 |
|
35 |
19 |
$2K |
| D2331 |
|
17 |
12 |
$2K |
| D2330 |
|
20 |
13 |
$2K |
| D0603 |
|
5,343 |
5,065 |
$0.01 |
| D0602 |
|
978 |
940 |
$0.00 |
| D0601 |
|
1,439 |
1,387 |
$0.00 |
| D1330 |
|
95 |
95 |
$0.00 |